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of 22 HMMC Guidance on the use of ONS for Adults in Hertfordshire (Nov 2012) – September 2015 Update

Guidelines for the Appropriate Use of Oral Nutritional Supplements (ONS) for Adults in Primary Care

CONTENTS Page

Aim, Introduction, Scope and Purpose of Guidelines 2 MUST – Malnutrition Universal Assessment Tool 3

7 Steps to Appropriate Prescribing of ONS in Adults 5

STEP 1: Identification of nutritional risk 5

STEP 2: Assessment of causes of malnutrition 5

STEP 3: Setting a treatment goal 6

STEP 4: Offering ‘FOOD FIRST’ advice 6

STEP 5: Prescribing ONS including 1st, 2nd and 3rd line product choices 7

STEP 6: Reviewing ONS and STEP 7: Discontinuing ONS and follow up 8 -9

Inappropriate ONS prescribing 9 ONS Care Pathway in Primary Care 11

ONS Product Choice Algorithm when initiating ONS in Primary Care 12

Over the Counter Supplements 13

1st line ONS: Powdered shake 14 2nd line ONS: Ready to drink milkshake style liquid 15

3rd line ONS: Juice style 16

ONS that should not routinely be started in primary care 17 Patient Groups for Special Consideration

Substance Misusers 18

Palliative Care 19

Diabetes 20

Cardiovascular Disease 20

Renal Disease 20

Guide to Assessing Underlying Causes of Malnutrition and treatment options 21

Further Reading, Resources and Acknowledgements 22 Appendix 1 - MUST Tool, Recording Sheets and Nutritional Support Pathway

Appendix 2 - Food intake chart

Appendix 2.1- Making More of your Food for Bed Based Units i.e for Bed Based Intermediate Care Units and Nursing Homes

Appendix 2.2- Making More of your Food i.e for Primary Care & Community

Appendix 3 - Nourishing drinks Patient Information

Appendix 4 - Food First Advice Patient Information

Appendix 4.1 – PrescQIPP Fabulous Fortified Feasts Recipes

Appendix 5 - Supplement drinks Patient Information

Appendix 6 - 7 Steps to the appropriate prescribing of Oral Nutritional Supplements in Primary Care

Appendix 7 - Prescribing ONS in Primary Care – Quick Reference Guide

Appendix 8 - Care Home ONS Prescription Request Form

Appendix 9 - West Hertfordshire Hospital Trust (WHHT) Dietitian ONS Prescription Request Letter Template

Appendix 10 - Hertfordshire Community Trust (HCT) Dietitian ONS Prescription Request Letter Template


Aim These guidelines aim to promote the appropriate, rational and cost effective prescribing of Oral Nutritional Supplements (ONS) in adults in primary care and supports national guidance from National Institute of Clinical Excellence (NICE) and other health professional organisations.

ONS is commonly referred to as ‘supplement drinks’ by patients.

Introduction “Malnutrition” can refer to both under and over nutrition, these guidelines refer to undernutrition; a deficiency of energy, protein and important micronutrients.

Untreated malnutrition has many consequences other than weight loss and can result in: • Reduced efficiency of the immune system resulting in increased risk of infection • Reduced muscle tone which affects respiratory muscles and respiratory function. Reduced

muscle tone can also lead to swallowing difficulties (dysphagia) • Impaired thermoregulation resulting in a predisposition to hypothermia • Impaired wound healing and delayed recovery from illness • The detrimental effect on mental state, apathy, depression and self neglect • Reduced digestive enzymes leading to inefficient take up of food and drugs • Increased risk of additional health care cost due to increase in:

o GP visits (65%) o hospital admissions (82%) o length of hospital stay (30%)

Tackling malnutrition can improve nutrition status, clinical outcomes and reduce health care use.

The National Institute for Health and Clinical Excellence Nutrition Support in Adults Clinical Guidelines 2006 (NICE CG32) has shown substantial cost savings can result from identifying and treating malnutrition, CG32 is ranked in the top clinical guidelines shown to produce cost savings.

ONS are nutritional supplements that are used with patients who have been identified as being nutritionally compromised. Use of nutritional supplements requires regular monitoring of the patient’s progress and should be discontinued once treatment goals have been achieved.

Alternative dietary approaches can be used to supplement dietary intake without using ONS.

Hertfordshire CCGs are committed to implementing a food first strategy and reserve the use of ONS for patients who have not responded to dietary measures alone as per NICE CG32, 2006.

Scope and Purpose of Guidelines This guidance is intended for all qualified healthcare professionals working within Hertfordshire that recommend, prescribe, supply or administer ONS; specifically dietitians, GPs, care of the elderly doctors, nursing staff (practice nurses, community nurses, Macmillan and other specialist nurses), pharmacists and care home staff.

The guidelines advise on:

Who is at risk of malnutrition [STEP 1]

Assessing underlying causes of malnutrition [STEP 2]

Setting a treatment goal [STEP 3]

Food First advice and over the counter products or homemade fortified drinks [STEP 4]

Initiating prescribing of ONS [STEP 5] – ensuring patients meets ACBS criteria, which products to prescribe, how much to prescribe


Reviewing ONS prescriptions [STEP 6]

Discontinuing ONS prescriptions [STEP 7]

Advice is also offered for when prescribing is inappropriate, considerations for specific patient groups (palliative care, substance misusers, diabetic and renal patients) and when it is appropriate to refer to community dietetic services.

MUST – Malnutrition Universal Screening Tool MUST is a validated screening tool for adults and was specifically designed by a multi-disciplinary group of healthcare professionals to assess malnutrition risk in all care settings in a consistent way in order to facilitate continuity of care from one setting to another. It can be used by all types of care workers to identify malnutrition and is a simple 5-step screening tool that uses objective measurements when possible and subjective criteria when necessary. MUST is used throughout the NHS in primary and secondary care and includes an appropriate care plan linked to the risk of malnutrition (MUST score).

See page 5 and Appendix 1 - MUST, recording sheets and Nutritional Support Pathway

An online MUST calculator can be accessed at http://www.bapen.org.uk/screening-for-malnutrition/must-calculator There is also an ‘app’ available for iPhones/iPads for a simple MUST calculator. Search in the App Store for ‘BAPEN MUST’

http://www.bapen.org.uk/screening-for-malnutrition/must-calculator

http://www.bapen.org.uk/screening-for-malnutrition/must-calculator


Malnutrition Universal Screening Tool (MUST) and

Nutritional Support Pathway for Treating Patients at

Risk of Malnutrition – Primary Care (adapted for local use)

BMI Score

Weight Loss Score

Acute Disease Effect Score

Overall Risk of Malnutrition

Management Guidelines

BMI kg/m2 Score

>20 (>30 Obese) = 0 18.5 – 20 = 1 <18.5 = 2

Unplanned weight loss in past 3-6 months

% Score <5 = 0 5-10 = 1 >10 = 2

If patient is acutely ill and there has been or is likely to be no nutritional intake

for >5 days

Score 2

Add scores together to calculate overall risk of malnutrition Score 0: Low Risk Score 1: Medium Risk Score 2 or more: High Risk

Low Risk = 0

Routine Clinical Care

Weigh

Hospital – weekly Care Homes - monthly

Repeat screening if there are changes that cause concern or new episode of care

Medium Risk = 1

Observe and Monitor

Food Intake

Start MUST weight chart

Start food & fluid record chart

Give & discuss ‘Making the most of your food patient’ leaflet

Repeat screening monthly for 3 months, earlier if serious concern

o at home or o in surgery or o in care home

High Risk = >2

Observe and Monitor Food Intake and Treat

Set Treatment Goal

Start MUST weight chart

Start food & fluid record chart

Give ‘Food First’ advice & provide leaflets on ‘Making the most of your food’, ‘’Food First Advice’, Nourishing Drinks’

Patients with a MUST score of 3 or more & BMI<18.5kg/m2 should be referred to

dietetic services. Also refer complex patients

If improved or adequate intake and little clinical

concern (eating >50% of meals)

Monitor progress

Repeat screening every 3 months

Until at low risk

If deterioration or no improvement

(eating < 50% of meals/ weight loss)

Repeat screening every

two weeks

If further clinical concern

follow high risk score box

If no improvement

Prescribe ONS

twice daily

If treatment goal achieved

Monitor progress

Repeat screening every 1 -3 months

Until at low risk

Re-screen after one month

Review monthly against treatment

goal

If no progress or clinical concern, refer to dietitian

Treatment goal met -stop ONS


7 steps to appropriate prescribing of ONS in adults

For any individual patient the following steps should apply. ONS should only be introduced after Steps 1 – 4 have been completed and if nutritional intake is still inadequate.

STEP 1 Identification of Nutritional Risk

Nutritional screening should be standard practice in all inpatient settings (hospitals) and community healthcare settings (GP clinics, care homes). Patients should be assessed using the Malnutrition Universal Screening Tool (MUST) or alternative appropriate assessment screening tool (see page xx or Appendix 1 or use online/iPhone or iPad app MUST calculator).

NICE Clinical Guideline 32, Nutritional Support in Adults 2006, suggests the following criteria are used to identify those who are malnourished or at nutritional risk:

MUST score of 2 or more

Body mass index BMI <18.5 kg/m2

Unintentional weight loss >10% in the last 3-6 months

BMI<20 kg/m2 and unintentional weight loss >5% in the last 3-6 months

Have eaten or likely to eat little or nothing for more than 5 days or longer

Have poor absorptive capacity and/or high nutrient losses and/or increased nutritional need.

REFERRAL TO THE DIETETIC SERVICE

The following patients are at risk of developing re-feeding problems and should be referred to the dietetic service, without delay (if not already known to secondary care. Also see page 9):

Body mass index BMI <16 kg/m2

OR have had little or no nutritional intake for the last 10

OR have unintentionally lost >15% body weight within the last 3-6 months, except patients at the end of their lives (see page 9 – Inappropriate Prescribing of ONS and page 19 – Palliative Care)

*It is unlikely that these patients have not already been identified before and already known to the dietetic service)

Those with a MUST score of 3 or more and BMI <18.5 kg/m2 should be referred to the dietetic service but can be offered ‘Food First’ as outlined in STEP 4 and also an assessment of the underlying causes with the appropriate referrals as detailed in STEP 2

STEP 2 Assessment of causes of malnutrition (Global Nutritional Assessment)

Once nutritional risk has been established, the underlying cause and treatment options should be assessed and appropriate action taken. Consider availability of adequate diet and identify problems with reduced or altered food intake relating to:

Ability to feed using appropriate utensils Pressure sores

Poor mental health eg. dementia/depression Substance or alcohol misuse

Medication e.g. those that suppress appetite Social and environmental circumstances

Ability to chew (consider dental assessment) and swallow (consider speech therapy assessment). Patients with dysphagia may require a modified consistency diet and are likely to require supplements for longer periods

Physical symptoms e.g. pain, sore mouth, vomiting, constipation, diarrhoea

Medical prognosis – proactive nutritional support may not be appropriate in terminal illness

Review the treatment plan in respect of these issues and, if needed, make appropriate referrals. (See page 21 – A Guide to Assessing Underlying Causes of Malnutrition and Treatment Options)


STEP 3 Set Treatment Goals

Clear treatment goals and a care plan should be agreed with patients. Treatment goals should be documented on the patient record and should include the aim of the nutritional support, timescale, review period and be realistic and measurable. Suitable goals might consist of:

Attaining a target weight/ target weight gain/ target BMI over a specified period of time

Weight maintenance where weight gain is unrealistic or undesirable

Completion of wound healing, if relevant

STEP 4 Offer ‘FOOD FIRST’ advice Oral nutritional supplements (ONS) should NOT be used as first line treatment. A ‘FOOD FIRST’ approach should be used initially. Dietary counselling to encourage the use of energy and protein rich foods should be recommended as the initial interventions before prescribing ONS. This means offering advice on food fortification to increase calories and protein in everyday foods. Additional snacks will be needed to meet requirements of those with a small appetite.

Patients may be reluctant to eat high fat / sugar foods, so it is important to reinforce the message that the dietary needs of the malnourished are different to those of the healthy population.

Written information should be given to the patient/carer/care home to reinforce the advice: The following resources are available: Appendix 2.1: Making More of your Food for Bed Based Units i.e for Bed Based Intermediate Care Units and Nursing Homes Appendix 2.2: Making More of your Food i.e for Primary Care & Community Appendix 2.3: Food intake chart Appendix 3: Nourishing Drinks Appendix 4: Food First Advice Appendix 4.1: PrescQIPPs’ Fabulous Fortified Feasts – food fortification recipes, homemade sip feeds and snacks

Care homes should be able to provide adequately fortified foods and snacks and prepare homemade milkshakes and smoothies, which should negate the need to prescribe ONS in the majority of case. In addition, for patients in care homes, food fortifying care plans can be inserted into individual patient’s care plan to instruct care home staff regarding food fortification.

If patients prefer, they can purchase over the counter products such as Complan® milkshakes or soups, Meritene Energis® milkshakes or soups, AYMES® milkshakes or soups or Nurishment® milkshakes. Please see page 13 for nutritional content and prices for these products. Patients who do not meet ACBS prescribing criteria (STEP 5) can also be advised to purchase over the counter supplements or prepare homemade nourishing drinks.

Patients should be reviewed one month after being offered this advice to assess the progress with a ‘FOOD FIRST’ approach. If there is a positive change towards meeting treatment goals, the changes should be encouraged and maintained and a further review arranged until goals are met.


STEP 5 Prescribing ONS

ONS prescribing should only be initiated in primary care in addition to the ‘FOOD FIRST’ changes which should be maintained: - 1. If first line dietary measures/ ‘FOOD FIRST’ approach have failed to achieve a positive change

towards meeting goals after one month. 2. Where there are clinical benefits to be realised and clear nutritional goals to work towards. Repeat

prescriptions should only be issued if there is an explicit plan for continuation [Step 3]. Goals should be regularly reviewed and prescribing should cease when goals are achieved [Step 6]

Patients must meet at least one of the ACBS criteria below to be eligible for prescribed ONS:

Short bowel syndrome

Intractable malabsorption

Pre-op preparation of undernourished patients

Proven inflammatory bowel disease

Following total gastrectomy

Bowel fistulae

Disease related malnutrition

Dysphagia

In addition, some supplements and food products are prescribable for those receiving continuous ambulatory dialysis (CAPD) and haemodialysis, or are specifically prescribable for individual conditions. These products should not be routinely started in primary care but normally requested by a dietitian.

If the patient does not meet the ACBS criteria then ‘over the counter’ nutritional supplements are recommended only (see page 13).

Starting prescriptions

To maximise their effectiveness and avoid spoiling appetite, patients should be advised to take ONS between or after meals and not before meals or as a meal replacement

To be clinically effective, it is recommended that ONS are prescribed for twice daily (bd) dosing. This ensures that calorie and protein intake is sufficient to achieve weight gain.

Prescriptions should be clearly marked “ACBS” and give clear directions for use e.g. “one to be taken twice daily between meals”. “As directed” should not be used as this has been shown to cause patients / carers to use the wrong dose.

A one week prescription or starter pack should always be prescribed initially to avoid wastage if products are not well accepted due to taste and palatability. Avoid prescribing starter packs of powdered ONS, except for an initial trial, as they often contain a shaker device which makes them more costly.

Issue monthly prescriptions for 1 -2 months once the patient has informed the practice of their preferred flavour.

Avoid adding prescriptions for ONS to the repeat medications list unless a short review date is included to ensure review against treatment goals.

Provide written information to patient and/or carer regarding their ONS (supplement drinks) to inform patient of why they are taking it and when they will stop. This will help manage patient expectation of duration of treatment.

(See Appendix 5 – Supplement Drinks Patient Information)

Prescribing choices should be in line with the primary care 1st, 2nd and 3rd line ONS.


1st line ONS – Powdered Shake: The preferred product in primary care is AYMES® Shake.

Alternatives are Ensure® Shake, Complan® Shake and Fresubin® Powder Extra which can be prescribed for patient palatability or taste preferences. These should be mixed with 200ml full fat milk as per manufacturers’ instructions. Nutritional content and prices are shown on page 14.

2nd line ONS – ready to drink Liquid: Consider when a 1st line powered ONS is not suitable i.e.

patient is lactose intolerant or if patient has difficulties preparing the powdered shake. The preferred product in primary care is Aymes® Complete. Alternatives for patient taste preferences are Ensure® Plus Milkshake Style or Fortisip®. These are all clinically lactose free. Where volume is a problem, Nutriplen®, Ensure® Compact or Fortisip® Compact can be used to prevent waste and improve compliance. Nutritional content and prices are shown on page 15.

3rd line ONS – Juice style drinks: Consider when 1st or 2nd line ONS are unacceptable because the

patient dislikes milky drinks. The preferred products in primary care are Resource® Fruit, Ensure Plus® Juce or Fresubin® Jucy. Nutritional content and prices are shown on page 16.

STEP 6 Reviewing ONS Patients on ONS should be reviewed regularly. It is the responsibility of the prescriber to ensure that patients are adequately monitored to assess progress towards goals and whether there is a continued need for ONS on prescription. The following parameters should be monitored monthly:

Weight/BMI/wound healing depending on goal set – if unable to weigh patient, record other measures to assess if weight has changed e.g. mid-upper arm circumference, clothes/rings/watch looser or tighter, visual assessment

Changes in food intake

Compliance with ONS and stock levels at home/ care home

Patients requiring longer term ONS should be assessed at least every 3 months to review on-going need and treatment goals.

Prescription Requests from Care Homes When a care home requests a prescription for ONS for their patient, the patient’s weight, BMI and MUST score and treatment goal should be provided. See Appendix 8 – ‘Care Home ONS Prescription Request Form’ which is recommended for care homes to use to provide this information when requesting a prescription.

Prescription Requests from Hospital and Community Dietitians Hospital and community dietitians requesting continuation of ONS post discharge or following a clinic appointment must clearly state the treatment goals and patient’s target weight/weight gain/BMI on the discharge summary/ clinic appointment letter to enable continued prescribing and appropriate monitoring in primary care. See Appendix 9 – West Hertfordshire Hospitals Trust (WHHT) Dietitian ONS Prescription Request Template See Appendix 10 – Hertfordshire Community NHS Trust (HCT) Dietitian ONS Prescription Request Template

Patients discharged from hospital should not routinely be prescribed ONS as part of TTA medication unless a dietitian assessed the patient and approved the continued use. These patients may have been started on ONS products which are not the primary care preferred cost-effective choices. In these cases, a switch to the preferred primary care ONS product is recommended. This switch in primary care is fully supported by the local hospital and community dietetic teams and patients will have been informed of this likelihood. There will be instances where it would NOT be appropriate to switch to the preferred choice in primary care and the reason will be clearly stated in the communication letter from the hospital or community dietitian.


STEP 7 Discontinuing ONS and follow up

When treatment goals are met, discontinue treatment.

Review one month after the discontinuation of ONS to ensure that there is no recurrence of the precipitating problem.

Should the patient wish to continue with ONS and it is no longer indicated by ACBS criteria or treatment goals are met, the use of ‘over the counter’ supplements (e.g. Complan®, AYMES®, Mertitene Energis® or Nurishment®) should be recommended.

Nutritional content and prices are shown on page 13.

Referral for specialist dietetic input (STEPS 4 -7)

Dietetic referral may be appropriate in any of the following circumstances: • To advise on nutritional supplementation strategies and the appropriateness or otherwise of

initiating oral nutritional supplements • To assist in appropriate planning and goal setting for nutritional support for individual patients • Deterioration in nutritional status despite supplementation after excluding other contributory

pathology • Apparent requirement for ONS longer than 3 months • The presence of co-existing medical conditions such as diabetes, renal and liver disease,

malabsorption, coeliac disease or high cardiovascular risk or any other condition which may indicate complex patient

• Where swallowing difficulties or other indications for modified texture exist. Assessment by Speech and Language Therapist will be required before dietetic input

Inappropriate prescribing of ONS

Care homes should provide adequate quantities of good quality food so that the use of unnecessary nutrition support is avoided. ONS should not be used as a substitute for the provision of food. Suitable snacks, food fortification as well as homemade milkshakes and smoothies and over the counter products can be used to improve the nutritional intake of those at risk of malnutrition. (See Appendix 2, 3, 4 and 4.1).

Patients should not be routinely discharged from hospital on ONS without dietetic assessment and review process in place. These patients will not automatically require ONS on prescription once home. They may have required ONS whilst acutely unwell or recovering from surgery, but once home and eating normally the need is negated. Therefore, unless the request to prescribe ONS following hospital discharge is from the dietetic team, it is recommended that the GP does not prescribe without first assessing need in line with these 7 step guidelines. Where ONS are still required, a switch to the primary care cost-effective preferred product is recommended.

Avoid prescribing less than the clinically effective dose of 2 sachets/bottles daily which will provide 600-800kcal/day. Once daily prescribing provides amounts which can be met with food fortification alone and will delay resolution of the problem.

Patients with complex nutritional needs e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes and gastrointestinal disorders may require specialist products and should be referred to local community dietetic services, if not already known to the service.

Patients with swallowing problems will require assessment by a Speech and Language Therapist (SLT) before ONS can be safely prescribed and before dietetic input. These patients may require


ready thickened ONS or dessert/pudding style ONS to ensure the required consistency is provided in the supplement. Only prescribe ONS on the recommendation of a dietitian following a SLT assessment (see page 17).

Patients in the final days or weeks of life are unlikely to benefit from ONS. Over the counter products can be recommended if required. See page 19 - Palliative Care and ONS Prescribing).

Patients with diabetes should not routinely be prescribed fruit juice based ONS i.e. Fresubin® Jucy, Ensure® Plus Juce. This is because these products have a higher glycaemic index, and blood glucose levels will need monitoring, with possible changes required to medication.

Patients who are substance misusers should not routinely be prescribed ONS. (See guidance on page 18 - Substance Misusers).

Do not initate ONS listed on pages 17-18 ‘ONS which should not be started in primary care’ unless a dietitian has requested and clinically justified the product


ONS CARE PATHWAY IN PRIMARY CARE

STEP 1: Patient identified as requiring oral nutritional support Refer the following to community dietetic services:

Those with MUST score≥3 and BMI<18.5kg/m2

Without delay those at risk of re-feeding syndrome or who rely on ONS as sole source of nutrition

Complex patients (diabetes, renal and liver disease, malabsorption, coeliac disease, high CV risk)

STEP 2: Assess underlying causes of malnutrition and availability of adequate diet Make changes to treatment plan and refer to other services as needed

STEP 3: Set a treatment goal (set target weight/weight gain or target BMI)

STEP 4: Offer ‘Food First’ advice Review after one month – has there been progress toward treatment goal set?

NO progress towards set goal

STEP 5: Prescribe ONS Reinforce ‘Food First’ advice

Reassess underlying problems and treat

If ACBS criteria met, prescribe ONS as per guideline in addition to fortified foods. If does not meet ACBS criteria, recommend over the counter supplements to purchase

Reassess after 1 week trial of ONS and prescribe preferred flavour twice daily for 1 month and then review

Yes, there is progress towards set goal

Reinforce advice.

Reassess after 1-3 months until goal met

If problems re-occur, return to start of ONS care pathway flowchart

STEP 6: Reviewing ONS Continued improvement or progress

Reinforce advice.

Check compliance to ONS and any changes in food intake or other underlying cause

Reassess after 1-3 months until goal met

Treatment goal met STEP 7: Discontinue ONS

Review after 1-3 months. If patient still wish to take ONS, suggest over the counter products (AYMES®, Complan®, Meritene Energis® or Nurishment®) or homemade nourishing drinks

If problems re-occur, return to start of ONS care pathway flowchart

No progress or improvement

Refer to community dietetic service


ONS PRODUCT CHOICE ALGORITHM WHEN INITIATING ONS PRESCRIBING IN PRIMARY CARE

Does the patient meet ACBS criteria? Suggest patient/carer to purchase over

the counter supplements (AYMES®, Complan®, Mertiene Energis® or Nurishment®)

Is patient lactose intolerant OR cannot make up a powder shake due to limited

dexterity or impaired cognition and does not have access to a carer

*1st LINE ONS – POWDERED SHAKE AYMES® Shake

Mix the contents of one sachet with 200ml full fat milk and drink twice daily between meals

Available as starter pack (box of 5x57g sachets of mixed flavours with a shaker) and a box of 7x57g

sachets of one flavour: vanilla, banana, chocolate, strawberry & neutral. Alternative

products for patient taste or palatability preferences: Ensure® Shake, Complan® Shake,

Fresubin® Powder Extra. Note: Nutritionally

incomplete - do not use as sole source of nutrition

*2ND LINE ONS – READY TO DRINK MILKSHAKE STYLE LIQUID

AYMES® Complete

Alternatives for patient palatability/taste- Ensure® Plus Milkshake Style or Fortisip®

One bottle twice daily between meals Note: Liquid ONS are nutritionally complete

Patient unable to tolerate twice daily ONS because the volume is too large, creating waste of ONS

AYMES® Shake and Ensure® Shake These can be mixed with 100ml full fat milk if a

low volume ‘compact style’ ONS is required

*Low volume ‘compact’ style milkshake

125ml bottles

Nutriplen® Ensure® Compact } not clinically Fortisip® Compact } lactose free

One bottle twice daily between meals

Patient has dislike of milky drinks and finds the powdered shake or liquid milkshake unacceptable

*3RD LINE ONS – JUICE STYLE DRINKS

Ensure® Plus Juce (lactose free) Resource® Fruit } not clinically Fresubin Jucy } lactose free

Patient has been identified as requiring oral nutritional support (MUST score ≥2, BMI<18.5kg/m2, weight loss); nutritional assessment done and referral made to appropriate local services; complex patients referred to dietetic services; treatment goal set (target weight/weight gain or target BMI); ‘Food First’ advice offered

[i.e. STEPS 1 -4 of appropriate prescribing of ONS in adults – see pages 5-6 of guidelines]. Failure to improve nutritional status or functional status after one month

NO

YES

NO

YES

*Refer to pages

13-18 of guidelines for full details of

ONS products

Note: Not recommended for use in diabetic patients due to high glycaemic index. Do not use as sole source of nutrition – nutritionally incomplete


Over the Counter Supplements These products are available to buy at pharmacies and larger supermarkets.

They are suitable for those who do not meet ACBS prescribing criteria and/or do not have the ability or do not wish to make homemade milkshakes.

These products are not suitable as sole source of nutrition and should not be used as tube feeds.

These products should not be prescribed on the NHS.

Powdered Products

Presentation Nutritional content per sachet mixed with 200mls full fat milk

Approx. Retail Cost per sachet#

AYMES® sachets (available end of November 2015)

1 box of 4 x 38g sachets Vanilla, banana, strawberry and chocolate flavours

265kcal

15.1g protein

75p

Complan® sachets 1 box of 4 x 57g sachets Vanilla, banana, strawberry, chocolate and neutral flavours

387kcal

15.6g protein

85p

Meritene Energis® 1 x 30g sachet of one flavour Vanilla, strawberry, and chocolate flavours

200kcal*

16.0g protein* *Semi-skimmed milk

£1.32

Powdered Products

Presentation

Nutritional content per serving (8 scoops)

Approx. Retail Cost per 425g

box#

Complan® Original 1 box of 425g neutral flavour

244kcal

8.5 protein

£4.50

Soups Presentation Nutritional content per sachet mixed with 200mls water

Approx. Retail Cost per sachet#

AYMES® soup (available end of November 2015)

1 box of 4 x 49g sachets chicken flavour

207kcal

7.7g protein

75p

Complan® soup 1 box of 4 x 55g sachets chicken flavour

243kcal

8.7g protein

83p

Meritene Energis® soup

1 x 50g sachet Chicken, and vegetable flavours

207kcal

7.0g protein

£1.40

Liquid Products Presentation Nutritional content per unit

Approx. Retail Cost per unit#

Nurishment ® Original

400g tin Vanilla, banana, strawberry, raspberry, peanut, mango & chocolate flavours

428kcal

21g protein

£1.30

Nurishment® Extra

310ml bottle Vanilla, banana, strawberry and chocolate flavours

342kcal

12.4g protein

£1.10

Nurishment® Active

500ml bottle Vanilla, strawberry and chocolate flavours

465kcal

35g protein

£1.99

Complan® Smoothie

250ml tetrapak Tropical and berry flavours

279kcal

10g protein

£1.79

# costs accessed 15/9/15 http://www.chemistdirect.co.uk


Powdered ONS to prescribe as 1st line These products are not suitable as sole source of nutrition and should not be used as tube feeds

Choice of ONS powder shake product should be based on patient palatability and taste preference. Prescribe an alternative product if patient does not tolerate the taste or does not find palatable

Starter pack (shaker and mix of flavours) is available for AYMES® Shake and Complan® Shake

All powder shakes to be mixed with 200ml full fat milk as per manufacturer’s instructions

If patient cannot take the full volume, then AYMES® Shake and Ensure® Shake can be mixed with 100ml of milk to make a ‘compact’ style ONS. This will prevent wastage and improve compliance

1st LINE ONS – POWDER SHAKE

ONS Powder Shake Product Presentation Nutritional Content per sachet mixed with 200ml full fat milk

Cost per sachet

Pre

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ho

ice

AYMES® Shake

1 box of 7 x 57g sachets of one flavour. Vanilla, banana, strawberry, chocolate and neutral flavours

388kcal

15.7g protein

70p* [*Price from 1st Jan 2016. Previous price 78p]

AYMES® Shake starter pack

1 box of 5 x 57g sachets of mixed flavours with a shaker 96p

Alt

ern

ativ

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or

pal

ata

bili

ty

and

ta

ste

pre

fere

nce

Ensure® Shake 1 box of 7 x 57g sachets of one flavour. Vanilla, banana strawberry and chocolate

389kcal

17.0g protein 78p

Complan® Shake

1 box of 4 x 57g sachets of one flavour. Vanilla, banana, strawberry, chocolate and neutral flavours

387kcal

17.7g protein

78p* [*Price from 1st Jan 2016. Previous price 85p]

Complan® Shake starter pack

1 box of 5 x 57g sachets of mixed flavours with a shaker

95p

Fresubin® Powder Extra

1 box of 7 x 62g sachets of one flavour. Vanilla, strawberry, chocolate and neutral flavours

397kcal

17.7g protein 80p

Powdered ONS is the 1st line ONS to be prescribed in primary care UNLESS one of the

following applies: - Patient is intolerant to an ingredient in the powdered ONS e.g. lactose.

Patient has very limited dexterity (e.g. arthritis) or neuromuscular conditions (e.g. motor neurone disease) or impaired cognition and does not have access to a carer to make up the powdered ONS shake. This should be assessed on an individual patient basis.

Patient is on a liquid only diet due to an inability to tolerate solid foods (e.g. inflammatory bowel disease, oesophageal stricture, neck/GI tumours requiring radiotherapy). These patients will require a liquid ONS which is nutritionally complete since this will be used as a sole source of nutrition. Ready to drink liquid ONS are nutritionally complete (contains full range of vitamins and minerals) whereas powdered ONS are not. This is not an issue when powdered ONS are used to supplement oral nutrition in patients who are able to eat normal fortified meals.

Patient is on fluid restriction (e.g. refractory ascites, chronic heart failure). The patient will require a


high energy concentrated liquid ONS.

Patient with renal impairment: - o Powdered ONS contains a higher potassium content which may cause hyperkalaemia. This may be

potentiated if the patient is also taking a potassium sparing medication e.g. ACE-inhibitor. o Patient with chronic kidney disease taking phosphate binders. Milk based powdered ONS contains

a higher phosphate content.

Patient with diabetes. Powdered ONS contains higher sugar and carbohydrate content than ready to drink liquid ONS products. These patients should not be switched to alternative products as these may have varying carbohydrate contents.

Patient requiring liquid ONS as part of an enteral feeding regimen administered via the enteral feeding route.

Patients who find the taste of milky drinks unacceptable may require a juice style ONS.

Please note that this list is not exhaustive.

When the above patients has been started on a ready to drink liquid ONS by a hospital or community dietitian, then it would NOT be appropriate for these patients to be switched to the powdered ONS in primary care. This will be clearly stated in the communication letter from the hospital or community dietitian.

Liquid ONS to prescribe as 2nd line if powders not suitable

Consider 2nd line ready to drink liquid ONS if patient has difficulty preparing the powder shake or if patient is lactose intolerant (powder shakes contain lactose) or when one of the above situations apply. If patient cannot take the full volume, then use a ‘compact’ style ONS (125ml) to prevent wastage and improve compliance.

Alternatives can be used for patient taste and palatability preferences.

2nd line ONS (ready to drink liquid milkshake style)

Presentation Nutritional content per bottle

Cost per bottle

Pre

ferr

ed

cho

ice

AYMES® Complete when patient is lactose intolerant or cannot make up a shake

200ml bottle Vanilla, strawberry, banana and chocolate flavours

300kcal

12g protein

£1.26* [*Price from 1st Jan 2016. Previous price £1.40]

Alt

ern

ativ

es f

or

pal

ata

bili

ty

and

ta

ste

pre

fere

nce

Ensure® Plus Milkshake when patient is lactose intolerant or cannot make up a shake

220ml bottle Strawberry, chocolate, fruit of forests, vanilla, banana, coffee, neutral, orange, peach, raspberry flavours

330kcal

13.8g protein

£1.40

Fortisip bottle when patient is lactose intolerant or cannot make up a shake

200ml bottle Neutral, vanilla, banana chocolate, toffee/caramel, orange, strawberry, and tropical flavours

300kcal

12g protein

£1.40 [*Price from 1st Jan 2016. Previous price £2.06]


2nd line ONS (ready to drink liquid when a small volume ‘compact’ style is required)

Presentation Nutritional content per 125ml bottle

Cost per 125ml bottle

Nutriplen® when patient is lactose intolerant

4 x 125ml bottles Strawberry, vanilla, banana & hazel chocolate flavours

300kcal

12g protein £1.45

Ensure® Compact Note – this is not clinically lactose free

125ml bottle Vanilla, strawberry and banana flavours

300kcal

13g protein £1.45

Fortisip® Compact Note – this is not clinically lactose free

125ml bottle Vanilla, strawberry, banana, mocha, apricot, forest fruit and chocolate

300kcal

12g protein

£1.45 [*Price from 1st Jan 2016. Previous price £2.02]

2nd line ONS (ready to drink liquid with a higher calorie and protein content)

Presentation Nutritional content per unit

Cost per unit

Fresubin® 2kcal when patient is lactose intolerant and has high calorie and protein requirements e.g for wound healing

200ml bottle Vanilla, toffee, apricot peach, cappuccino, fruits of the forest and neutral flavours

400kcal

20g protein £1.96

Juice Style ONS to prescribe as 3rd line if powders and milkstyle ONS are not suitable

Juice style supplements can be used if 1st and 2nd line ONS are unacceptable i.e. when patient dislikes milky drinks

These are not nutritionally complete and should not be used as a sole source of nutrition

These should not be routinely used in diabetic patients due to their high glycaemic index

These are fat free so can be used in patients requiring a fat free diet (e.g. pancreatitis)

3rd line ONS (juice style)

Presentation Nutritional content per unit

Cost per unit

Resource® Fruit

200ml bottle Orange, apple, pear-cherry, raspberry-blackcurrant

250kcal

8g protein

contains lactose

£1.84

Fresubin® Jucy

200ml bottle Orange, apple, pineapple, cherry and blackcurrant flavours

300kcal

12g protein

contains lactose £1.93

Ensure® Plus Juce

220ml bottle Orange, apple, lemon and lime, strawberry, peach, fruit punch flavours

300kcal

10.6g protein

lactose free £1.97


ONS that should not routinely be initiated in primary care The ONS listed below should not routinely be initiated in primary care unless directed by a dietitian. These will sometimes be used by dietitians either alone or in conjunction with other ONS where first line products are not sufficient to meet individual patients’ nutritional needs or are not suitable.

However these patients should always be under review by the dietitian. These include:

low calorie products i.e. 1kcal/ml since these are not cost effective

milkshake style ONS which are not first or second line products in primary care

modular supplements which do not provide a balance of nutrients

specialist products which may be required for particular patient groups e.g. renal patients, or those with bowel disorders, those with pressure ulcers, or those with dysphagia

thickened supplements and crème style puddings and desserts. These may be required for patients with swallowing difficulties (dysphagia) who have difficulty mixing powdered thickener into either powdered shakes or liquid ONS or who are not compliant with thickened drinks made with powdered thickener. Some powder and liquid ONS do not provide a consistent modified texture when mixed with powdered thickener. Pre-thickened supplements and desserts/puddings reduce the risk of aspiration by removing potential for error and should only be recommended under the guidance of a Speech and Language Therapist.

puddings/desserts or soups as it should usually be possible for suitable homemade products to be fortified (unless recommended for dysphagia)

yoghurt style ONS – they may be useful in patients who experience taste changes e.g. as a side-effect to cancer treatments

other ONS which are not cost effective It is not a fully comprehensive list. Please contact the dietitian or Pharmacy and Medicines Optimisation Team if you have queries about these or other supplements.

ONS that should not routinely be initiated in primary care (this list is not exhaustive)

Product Presentation Description of product

Fresubin® Original 200ml bottle 1kcal/ml ONS

Ensure® 250ml can 1kcal/ml ONS

Resource® Energy 200ml bottle Milkshake style ONS

Fresubin® Energy 200ml bottle Milkshake style ONS

Fortisip® Yogurt style 200ml bottle Yogurt style ONS

Fortisip® Savoury Multifibre 2 x 200ml cups Soup style ONS

Ensure® Plus Savoury 220ml bottle Soup style ONS Vitasavoury® 33g cups, 50g sachets Soup style ONS

Fresubin® Energy Fibre 200ml bottle Milkshake style ONS with fibre

Fortisip® Multifibre 200ml bottle Milkshake style ONS with fibre

Fortisip® Compact Fibre 125ml bottle Milkshake style ONS with fibre Ensure® Plus Fibre 200ml bottle Milkshake style ONS with fibre

Fortimel® Regular 200ml bottle Milkshake style ONS with high protein

Fortisip® Extra 200ml bottle Milkshake style ONS with high protein

Ensure® Twocal 200ml bottle Milkshake style ONS with high protein Fortijuce® 200ml bottle Juice style ONS

Calogen® 200ml & 500ml bottle Modular supplement

Calogen® Extra 40ml shots & 200 ml bottle Modular supplement

Fresubin® 5kcal shot drink 4 x 120ml bottle Modular supplement Pro-Cal® shot, singles and powder

6 x 250ml bottle, 60 x 30ml shots, 510g tin

Modular supplement


Product Presentation Description of product

Calshake® 7 x 87g sachet Modular supplement Scandishake® Mix 6 x 85g sachet Modular supplement

Ensure® Plus Creme 4 x 125g pots Dessert

Forticreme® Complete 4 x 125g pots Dessert

Fresubin® Creme 4 x 125g pots Dessert Fresubin® YoCreme 4 x 125g pots Dessert

Resource® Dessert Energy 125g cup Dessert

Resource® Dessert Fruit 3 x 125g cups Dessert

Fresubin® Thickened Stage 1 4 x 200ml bottles Pre-thickened ONS Fresubin® Thickened Stage 2 4 x 200ml bottles Pre-thickened ONS

Nutilis® Complete Stage 1 4 x 125ml bottles Pre-thickened ONS

Nutilis® Complete Stage 2 4 x 125ml bottles Pre-thickened ONS

Vital® 1.5kcal 200ml bottle Specialist product for bowel disorders Modulen® IBD 400g tin Specialist product for bowel disorders

Nepro® 200ml bottle Specialist product for renal disease

PATIENT GROUPS FOR SPECIAL CONSIDERATION

Substance misusers

Substance misuse (drug and alcohol misuse) is not a specified ACBS indication for ONS prescription.

Substance misusers may have a range of nutritional problems such as: • Poor appetite and weight loss • Nutritionally inadequate diet • Constipation (drug misusers in particular) • Dental decay (drug misusers in particular)

Problems created by prescribing ONS for Substance Misusers: • Once started and established on ONS, it may be difficult to stop the individual taking them • ONS may be taken instead of meals and therefore provide no benefit • They may be given to others i.e. family / friends • They may be sold and used as a source of income • These patients can be poor clinic attendees, therefore making it difficult to monitor and reassess

need for ONS ONS should not be prescribed in substance misusers unless all the following criteria are met: • BMI < 18 kg/m2 • AND there is evidence of significant weight loss (>10%) in the past 3 to 6 months • AND there is a co existing medical condition that could affect weight or food intake • AND once nutritional advice has been advised and tried • AND the patient is in a rehabilitation programme e.g. methadone or alcohol programme or on the

waiting list to enter a programme • Or they are within the ACBS categories

If ONS is initiated: • The patient should be assessed and monitored by a dietitian. If they fail to attend clinic

appointment on two consecutive occasions ONS should be discontinued • Maximum prescription should be for 600 Kcal / day (300 Kcal twice daily) • Prescribed on a short term basis only (i.e. 1-3 months)


• If there is no change in weight after three months, ONS will be reduced and discontinued • If weight gain occurs, continue until the treatment goals are met (e.g. usual or healthy weight/BMI)

and then reduce and stop ONS • If the individual still wishes to continue using a supplement, recommend ‘over the counter’

nutritional supplements (e.g. Complan®, Mertitene Energis® or Nurishment®). See page x for nutritional content and prices

Palliative Care Consideration should be given to the patient’s prognosis and their quality of life. ONS usage is common among palliative care patients, however the rationale and purpose of such a prescription needs to be carefully considered. Use of ONS in palliative care should be assessed on an individual basis. Appropriateness of ONS will be dependent upon the patient’s health and their treatment plan. Emphasis should always be on the enjoyment of nourishing food and drinks and maximising quality of life. Management of palliative patients has been divided into three stages: early palliative care, late palliative care and the last days of life. Care aims will change through these stages. Loss of appetite is a complex phenomenon that affects both patients and carers. Health and social care professionals need to be aware of the potential tensions that may arise between patients and carers concerning a patient’s loss of appetite. This is likely to become more significant through the palliative stages and patients and carers may require support with adjusting and coping. The patient should always remain the focus of care. Carers should be supported in consideration of the environment, social setting, food portion size, smell, presentation and their impact on appetite. ONS should not be prescribed just for the sake of ‘doing something’ especially if other dietary treatments have failed. Nutritional management in early palliative care

In early palliative care, the patient is diagnosed with a terminal disease but death is not imminent. Patients may have months or years to live and may be undergoing palliative treatment to improve quality of life.

Nutrition screening and assessment in this patient group is a priority and appropriate early intervention could improve the patient’s response to treatment and potentially reduce complications.

However, if a patient is unlikely to consistently manage 2 servings of ONS per day, then they are unlikely to derive any significant benefit to well-being or nutritional status from the prescription.

Following the 7 steps in this guideline is appropriate for this patient group. Particular attention should be paid to ‘ Step 2 – Assessment of causes of malnutrition’ (see page 5).

As the patient progresses into the late palliative care stage, consider reducing the prescribing quantity from monthly prescriptions to one or two weekly to avoid wastage.

Nutritional management in late palliative care

In late palliative care, the patient’s condition is deteriorating and they may be experiencing increased symptoms such as pain, nausea or reduced appetite.

The nutritional content of the meal is no longer of prime importance and patients should be encouraged to eat and drink foods they enjoy. The main aim is to maximise quality of life including comfort, symptom relief and enjoyment of food. Aggressive feeding is unlikely to be appropriate especially if this can cause discomfort, as well as distress and anxiety to the patient, family and


carers.

The goal of nutritional management should NOT be weight gain or reversal of malnutrition, but quality of life. Nutrition screening, weighing and initiating prescribing of ONS at this stage is NOT recommended. Avoid prescribing ONS for the sake of ‘doing something’ when other dietary advice has failed.

Nutritional management in the last days of life

In the last days of life, the patient is likely to be bed-bound, very weak and drowsy with little desire for food or fluid.

The aim should be to provide comfort for the patient and offer mouth care and sips of fluid or mouthfuls of food as desired.

Adapted from the Macmillan Durham Cachexia Pack 2007 and NHS Lothian guidance

Diabetes

Obtaining optimal blood glucose control may not be a priority over dietary measures to reduce malnutrition risk. This depends on the patient’s diagnosis, prognosis and degree of malnutrition. The dietary treatment of malnutrition may require patients to have foods higher in fat and sugar than is usually recommended. For this reason tighter monitoring of blood glucose levels is recommended. Diabetes medications may need to be reviewed if oral intake has changed significantly. If ONS is indicated: -

Milk based products should be chosen in preference to juice based products due to lower glycaemic index value.

Diabetic patients requiring tight blood glucose control are advised to have their ONS with a snack to minimise the impact on their glycaemic control.

Switching ONS products is not recommended since alternative supplements may have varying carbohydrate content.

It is recommendation that diabetic patients should have no more than 2 ONS servings per day.

Cardiovascular disease

Patients with high cholesterol should be encouraged to choose foods with unsaturated fats (from plant origin) in preference to those with a high saturated fat content. Healthier choices to increase the overall calorific value of the diet include using margarine, nuts and seeds, avocados, hummus and plant oils (with the exception of palm and coconut oil).

Renal disease

The following should be considered in patients with renal disease: -

Patients with chronic kidney disease requiring phosphate restriction (usually patient will be taking phosphate binder medication) are not suitable for milk based powder shakes due to the higher phosphate content.

Patients with renal impairment and particularly if taking a potassium sparing medication e.g. ACE-inhibitor are not suitable for powdered ONS due to the higher potassium content which may cause hyperkalaemia.

Some supplements and food products are prescribable for those receiving continuous ambulatory dialysis (CAPD) and haemodialysis. These products should not be routinely started in primary care but are normally requested by a dietitian.


A GUIDE TO ASSESSING UNDERLYING CAUSES OF MALNUTRITION AND TREATMENT OPTIONS Adapted from Guidelines for Managing Adult Malnutrition and Prescribing Supplements Havering PCT 2006 and Oral Nutrition Support Pack Westminster PCT 2007

PROBLEM POSSIBLE SOLUTIONS

Medical conditions causing poor appetite e.g. nausea, diarrhoea, constipation, cancer, COPD etc

Poor emotional or mental health e.g. depression, isolation, bereavement

Poor dentition

Difficulties with swallowing or unable to swallow

Unable to do own shopping and/or cook and/or feed self

Experiencing financial difficulties

Alcohol or other substance misuse

GP/Community Matron/Community Nursing management

and appropriate medication

GP management, counselling, social clubs, day centres, Community

Psychiatric Nursing management

Refer to dentist and advise patient on appropriate/soft diet

Suggest home delivery of food, Meals on Wheels, help from relative/friends,

and refer to Social Services and/or Community Therapy team

Refer to Social Services benefits/ allowances review

Refer to speech and language therapy services

Refer to community drug and alcohol services


Further reading and resources 1. Baldwin C, Weekes CE. Dietary advice with or without oral nutritional supplements for disease-

related malnutrition in adults. Cochrane Database of Systemic Reviews 2011, Issue 9. Article No: CD002008. DOI: 10.1002/14651858.CD002008.pub4 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002008.pub4/abstract

2. Elia M. (Chairman and Ed) MUST Report: Nutritional screening of adults: a multidisciplinary responsibility. 2003 http://www.bapen.org.uk/pdfs/must/must_exec_sum.pdf

3. Elia M, Stratton RJ, Russell C et al. The cost of malnutrition in the UK and the economic case for the use of oral nutritional supplements (ONS) in adults. British Association Parenteral and Enteral Nutrition (BAPEN), 2005 http://www.bapen.org.uk/pdfs/health_econ_exec_sum.pdf

4. Elia M and Russel CA (Eds). Combating Malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutritio, led by BAPEN 2009.

5. London Procurement Programme. A guide to prescribing oral nutritional supplements in nursing and care homes (2011). http://www.lpp.nhs.uk/

6. Malnutrition Universal Screening Tool (MUST). Reviewed and reprinted August 2011 http://www.bapen.org.uk/

7. Managing Adult Malnutrition in the Community. Produced by a multi-professional consensus panel including the RCGP, RCN, BDA, BAPEN, PCPA, 2012 http://www.malnutritionpathway.co.uk/

8. Thomas B. and Bishop J. Manual of Dietetic Practice. 4th ed. Blackwell Publishing Ltd (2007) 9. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 32. Nutrition

support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. February 2006. http://www.nice.org.uk/

10. National Institute for Health and Clinical Excellence (NICE) Quality Standard for nutrition support in adults. NICE QS24, Nov 2012 http://www.nice.org.uk/

11. National Minimum Standards for Care Homes for Older People. Dept of Health, 2003 https://www.gov.uk/government/organisations/department-of-health

12. National Prescribing Centre. Prescribing of adult oral nutritional supplements (ONS). Guiding principles for improving the systems and processes for ONS use. 2012 http://www.webarchive.org.uk/wayback/archive/20140627111700/http://www.npc.nhs.uk/quality/ONS/resources/borderline_substances_final.pdf

13. Stratton RJ, Elia M. Encouraging appropriate, evidence based use of oral nutritional supplements. Proc Nut Soc 2010; 69 (4): 477-487

Acknowledgements Central Eastern Commissioning Support Unit Medicines Management Team

PrescQIPP The following dieticians have contributed to the development of these guidelines:

Judith Harding, Prescribing Support Dietitian, Medicines Management Team, Basildon and Brentwood CCG

Nikki Stewart, Clinical and Operational Lead for Dietetics, Hertfordshire Community Trust

Marion Harvey, Dietitian, West Hertfordshire Hospitals Trust

Smita Ganatra, Therapy Lead for Dietetics, West Hertfordshire Hospitals Trust

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002008.pub4/abstract

http://www.bapen.org.uk/pdfs/must/must_exec_sum.pdf

http://www.bapen.org.uk/pdfs/health_econ_exec_sum.pdf

http://www.lpp.nhs.uk/

http://www.bapen.org.uk/

http://www.malnutritionpathway.co.uk/

http://www.nice.org.uk/

http://www.nice.org.uk/

https://www.gov.uk/government/organisations/department-of-health

http://www.webarchive.org.uk/wayback/archive/20140627111700/http:/www.npc.nhs.uk/quality/ONS/resources/borderline_substances_final.pdf

http://www.webarchive.org.uk/wayback/archive/20140627111700/http:/www.npc.nhs.uk/quality/ONS/resources/borderline_substances_final.pdf

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